The Effect of an Organized Trauma System on Mortality in Major Trauma Involving Serious Head Injury: A Comparison of the United Kingdom and Victoria, Australia

Early Surgery versus Initial Conservative Treatment in Patients with Traumatic Intracerebral Hemorrhage (STITCH[Trauma]): The First Randomized Trial

Intraparenchymal hemorrhages occur in a proportion of severe traumatic brain injury TBI patients, but the role of surgery in their treatment is unclear. This international multi-center, patient-randomized, parallel-group trial compared early surgery (hematoma evacuation within 12 h of randomization) with initial conservative treatment (subsequent evacuation allowed if deemed necessary). Patients were randomized using an independent randomization service within 48 h of TBI. Patients were eligible if they had no more than two intraparenchymal hemorrhages of 10 mL or more and did not have an extradural or subdural hematoma that required surgery. The primary outcome measure was the traditional dichotomous split of the Glasgow Outcome Scale obtained by postal questionnaires sent directly to patients at 6 months. The trial was halted early by the UK funding agency (NIHR HTA) for failure to recruit sufficient patients from the UK (trial registration: ISRCTN19321911). A total of 170 patients were randomized from 31 of 59 registered centers worldwide. Of 82 patients randomized to early surgery with complete follow-up, 30 (37%) had an unfavorable outcome. Of 85 patients randomized to initial conservative treatment with complete follow-up, 40 (47%) had an unfavorable outcome (odds ratio, 0.65; 95% confidence interval, CI 0.35, 1.21; p=0.17), with an absolute benefit of 10.5% (CI, -4.4-25.3%). There were significantly more deaths in the first 6 months in the initial conservative treatment group (33% vs. 15%; p=0.006). The 10.5% absolute benefit with early surgery was consistent with the initial power calculation. However, with the low sample size resulting from the premature termination, we cannot exclude the possibility that this could be a chance finding. A further trial is required urgently to assess whether this encouraging signal can be confirmed.

Impact of prehospital transfer strategies in major trauma and head injury: systematic review, meta-analysis, and recommendations for study design

BACKGROUND

It is unclear whether trauma patients should be transferred initially to a trauma center or local hospital.

METHODS

A systematic review and meta-analysis assessed the evidence for direct transport to specialist centers (SCs) versus initial stabilization at non-SCs (NSCs) for major trauma or moderate-to-severe head injury. Nine databases were searched from 1988 to 2012. Limitations in the study design informed recommendations for future studies.

RESULTS

Of 19 major trauma studies, five (n = 19,910) included patients not transferred to SCs and adjusted for case mix. Meta-analysis showed no difference in mortality for initial triage to NSCs versus SCs (odds ratio [OR] 1.03; 95% confidence interval [CI], 0.85-1.23). Within studies excluding patients not transferred to SCs, unadjusted analyses of mortality nonsignificantly favored transfer via NSCs (16 studies; n = 37,079; OR, 0.83; 95% CI, 0.68-1.01), whereas adjusted analysis nonsignificantly favored direct triage to SCs (9 studies; n = 34,266; OR, 1.18; 95% CI, 0.96-1.44). Of 11 head injury studies, all excluded patients not transferred to SCs and half were in remote locations. There was no significant mortality difference between initial triage to NSCs versus SCs within adjusted analyses (3 studies; n = 1,507; OR, 0.74; 95% CI, 0.31-1.79) or unadjusted analyses (10 studies; n = 3,671; OR, 0.87; 95% CI, 0.62-1.23).

CONCLUSION

This systematic review demonstrated no difference in outcomes for direct transport to a trauma center versus initial triage to a local hospital. Many studies had significant limitations in the design, and heterogeneity was high. Recommendations for future studies include the following: (i) inclusion of patients not transferred to SCs and those dying during transport; (ii) clear description of centers plus transport distances/times; (iii) adjustments for case mix; and (iv) assessment of morbidity and mortality.

LEVEL OF EVIDENCE

Systematic review, level IV.

Characterization of image transfer patterns in a regional trauma network

Trauma Networks are currently founded in Germany to improve patient care of severely injured persons. To assure appropriate patient treatment in a short time, the transfer of radiological image data between the connected hospitals over the internet is an important method. This paper characterizes radiological image transfer patterns in a regional trauma network and analyzes various compression options. Within the "TraumaNetwork NorthWest" in Germany, the web-based platform "MedSix" was developed. MedSix is able to transfer DICOM-data quickly and easily between connected hospitals and can be directly connected to the local PACS. Audit data of the routine system between the 01.01.2012 and the 31.12.2012 were analyzed to identify typical characteristics of radiological image exchanges. Five different compression methods were compared by a simulation. MedSix has been used by 12 hospitals. 87 % of the transfers were uploaded within 15 min. Lossless compression is able to save about 50 % bandwidth. 82 % of the transfers have a data volume of less than 200 MB. Temporary accounts for non-regular users were used regularly. Most transfers were done from small to maximum care hospitals. It is feasible to substitute physical image exchange in a trauma network with electronic exchange of radiological images between the connected hospitals. Even large datasets are transferred within an acceptable time frame. Most transfers occur from small to large hospitals. The possibility of temporary accounts seems to be a key feature for the user acceptance.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres

BACKGROUND

Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients.

METHODS

A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes.

RESULTS

Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0  years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network.

CONCLUSION

MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.

Opportunities for knowledge translation in the decade of road traffic safety

The United Nations has identified road traffic safety as an important objective for the decade 2011-2020. It has implemented a 5-tiered program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. A small body of practical research has been generated by the medical and surgical (including orthopaedic) communities regarding the road traffic safety, but a substantial amount of work remains to be performed. This article will review published research in each of the 5 tiers of the Decade of Action for Road Traffic Safety and will identify areas where research is insufficient or absent, such that new research programming and funding can be developed.

The trauma nurse coordinator in England: a survey of demographics, roles and resources

INTRODUCTION

Following the introduction of the regional trauma system in 2012 the role of the trauma nurse coordinator (TNC) has been rolled out. This study aims to determine the demographic and practice profile of nurses performing the TNC role in England.

METHODS

An electronic survey of TNCs across the 18 trauma networks in England was conducted.

RESULTS

Fifty-three TNCs responded (62%) to the survey. Seventeen different role titles identified. The majority of TNCs had an emergency or trauma/orthopaedics clinical background. The largest proportion of time spent was clinical (38%). Least amount of time was spent in the education (7%), and research (3%). Nearly a quarter of respondents (23%) had some form of formal research training, nearly half (47%) were assisting others in research. Over half (55%) of respondents felt that they did not have adequate human resources to conduct their role.

DISCUSSION

This research has provided baseline information about nurses in the role of TNC, their role titles and domains of the role 18 months after the formal introduction of trauma networks in England. There are some marked similarities and differences in the time spent in the different domains of the role between these findings and those published internationally.

Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis

Objective This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. Methods Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008–09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. Results There were 16 693 patients at a total cost of AU$178.7 million. The total costs incurred by trauma centres were $14.7 million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500 000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P < 0.001). Conclusions AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. What is known about this topic? Severely injured trauma patients often have multiple injuries, in more than one body region and the determination of appropriate AR-DRG can be difficult. Pilot research suggests that the AR-DRG do not accurately represent the care that is required for these patients. What does this paper add? This is the first multicentre analysis of treatment costs and coding variance for major trauma in Australia. This research identifies the limitations of the current AR-DRGS and those that are particularly problematic. The value of linking trauma registry and financial data within each trauma centre is demonstrated. What are the implications for practitioners? Further work should be conducted between trauma services, clinical coding and finance departments to improve the accuracy of clinical coding, review funding models and ensure that AR-DRG allocation is commensurate with the expense of trauma treatment.

Epidemiology of trauma: a population-based study of geographical risk factors for injury deaths in the working-age population of Norway

INTRODUCTION

Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality.

METHODS

All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16-66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates.

RESULTS

The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths.

CONCLUSION

Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.

Acute costs and predictors of higher treatment costs of trauma in New South Wales, Australia

BACKGROUND

Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma.

AIM

To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia.

MATERIALS AND METHODS

Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs.

RESULTS

There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179-10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p<0.001).

CONCLUSION

This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW.

The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review

BACKGROUND

UK trauma services are currently undergoing reconfiguration, but the optimum management pathway for head-injured patients is uncertain. We therefore performed a systematic review to assess the effects of routine inter-hospital transfer and specialist neuroscience care on mortality and disability in patients with non-surgical severe traumatic brain injury injured nearest to a non-specialist acute hospital.

METHODS

A protocol was registered with PROSPERO (CRD42012002021) and review methodology followed Cochrane Collaboration recommendations. A peer reviewed search strategy was implemented in an exhaustive range of information sources, including all major bibliographic databases, between 1973 and July 2013. Selection of eligible studies, extraction of relevant data and bias assessment were then performed by two independent reviewers. In the absence of homogeneous effect estimates at low risk of bias a narrative synthesis was pre-specified.

RESULTS

Four cohort studies, including a total of 4688 patients, were identified as potentially eligible after screening and bias assessment. Confounding by indication, arising from selective transfer of less severely injured patients, was the main limitation of included studies, with overall risk of bias rated as high for both mortality and disability effect estimates. Adjusted odds ratios for mortality favoured secondary transfer, ranging from 1.92 (95% CI 1.25-2.95) to 2.09 (95% CI 1.59-2.74). No convincing association was observed between non-specialist care and unfavourable outcome with a conditional odds ratio of 1.13 (95% CI 0.36-3.6).

CONCLUSIONS

There is limited evidence supporting a strategy of secondary transfer of severe non-surgical traumatic brain injury patients to specialist neuroscience centres. Randomised controlled trials powered to detect clinically plausible treatment effects should be considered to definitively investigate effectiveness.

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study

BACKGROUND

Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma.

INTRODUCTION

The evaluation of their influence on mortality during the last 15 years can lead to further improvements.

METHODS

In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value.

RESULTS

Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission (p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06).

CONCLUSION

Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.

Acute costs and predictors of higher treatment costs for major paediatric trauma in New South Wales, Australia

AIMS

To describe the costs of acute trauma admissions for children aged ≤15 years in trauma centres; to identify predictors of higher treatment costs and quantify differences in actual and state-wide average cost in New South Wales (NSW), Australia.

METHOD

Admitted trauma patient data provided by 12 trauma centres was linked with financial data for 2008-2009. Demographic, injury details and injury severity scores (ISS) were obtained from trauma registries. Individual patient costs, Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs were obtained. Actual costs incurred by each hospital were compared with state-wide AR-DRG average costs. Multivariate multiple linear regression identified predictors of cost.

RESULTS

There were 3493 patients with a total cost of AUD$20.2 million. Falls (AUD$6.7 million) and road trauma (AUD$4.4 million) had the highest total expenditure. The reduction in cost between ISS < 9 compared to ISS 9-12 and ISS > 12 was significant (P < 0.0001). The median cost of injury increased with every additional body region injured (P < 0.0001). For each additional day spent in hospital, there was an increased cost of AUD$1898 and patients admitted to an intensive care unit (ICU) cost AUD$7358 more than patients not admitted to ICU. The total costs incurred by trauma centres were AUD$1.4 million above the NSW peer group average cost estimates.

CONCLUSIONS

The high financial cost of paediatric patient treatment highlights the need to ensure prevention remains a priority in Australia. Hospitals tasked with providing trauma care should be appropriately funded and future funding models should consider trauma severity.

Standardising trauma monitoring: the development of a minimum dataset for trauma registries in Australia and New Zealand

INTRODUCTION

Trauma registries are central to the implementation of effective trauma systems. However, differences between trauma registry datasets make comparisons between trauma systems difficult. In 2005, the collaborative Australian and New Zealand National Trauma Registry Consortium began a process to develop a bi-national minimum dataset (BMDS) for use in Australasian trauma registries. This study aims to describe the steps taken in the development and preliminary evaluation of the BMDS.

METHODS

A working party comprising sixteen representatives from across Australasia identified and discussed the collectability and utility of potential BMDS fields. This included evaluating existing national and international trauma registry datasets, as well as reviewing all quality indicators and audit filters in use in Australasian trauma centres. After the working party activities concluded, this process was continued by a number of interested individuals, with broader feedback sought from the Australasian trauma community on a number of occasions. Once the BMDS had reached a suitable stage of development, an email survey was conducted across Australasian trauma centres to assess whether BMDS fields met an ideal minimum standard of field collectability. The BMDS was also compared with three prominent international datasets to assess the extent of dataset overlap. Following this, the BMDS was encapsulated in a data dictionary, which was introduced in late 2010.

RESULTS

The finalised BMDS contained 67 data fields. Forty-seven of these fields met a previously published criterion of 80% collectability across respondent trauma institutions; the majority of the remaining fields either could be collected without any change in resources, or could be calculated from other data fields in the BMDS. However, comparability with international registry datasets was poor. Only nine BMDS fields had corresponding, directly comparable fields in all the national and international-level registry datasets evaluated.

CONCLUSION

A draft BMDS has been developed for use in trauma registries across Australia and New Zealand. The email survey provided strong indications of the utility of the fields contained in the BMDS. The BMDS has been adopted as the dataset to be used by an ongoing Australian Trauma Quality Improvement Program.

Helicopter emergency medical services for adults with major trauma

BACKGROUND

Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit.

OBJECTIVES

The purpose of this review is to determine if helicopter emergency medical services transport (HEMS) is associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma. The primary outcome was survival to hospital discharge. Secondary outcomes were quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs).

SEARCH METHODS

Searches were run in CENTRAL, MEDLINE, EMBASE, CINAHL (EBSCOhost), SCI-EXPANDED, CPCI-S, and ZETOC in January 2012. Relevant websites were also searched, including controlled trials registers, HSRProj, the World Health Organization (WHO) ICTRP, and OpenSIGLE. Searches were not restricted by date, language, or publication status. Attempts were made to contact authors in the case of missing data.

SELECTION CRITERIA

Eligible trials included randomised controlled trials (RCTs) and non-randomised intervention studies. Non-randomised studies (NRS), including controlled trials and cohort studies, were also evaluated. Each study was required to have a GEMS comparison group. An injury severity score (ISS) > 15 or an equivalent marker for injury severity was required. Only adults aged 16 years or older were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the risk of bias of included studies. The Downs and Black quality assessment tool was applied for NRS. The results were analysed in a narrative review, and with studies grouped by methodology and injury type. A predefined subgroup was comprised of four additional studies that examined the role of HEMS versus GEMS for inter-facility transfer. Summary of findings tables were constructed in accordance with the GRADE Working Group criteria.

MAIN RESULTS

Twenty-five studies met the entry criteria for this review. Four additional studies met the criteria for a separate, predefined subgroup analysis of patients transferred to trauma centres by HEMS or GEMS. All studies were non-randomised studies; no RCTs were found. Survival at hospital discharge was the primary outcome. Data from 163,748 people from 21 of the 25 studies included in the primary analysis were available to calculate unadjusted mortality. Overall, considerable heterogeneity was observed and an accurate estimate of overall effect could not be determined. Based on the unadjusted mortality data from five trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS (relative risk (RR) 1.02; 95% CI 0.85 to 1.23). Nine studies used multivariate regression to adjust for confounding, the five largest indicated a statistically significant increased odds of survival associated with HEMS. All Trauma-Related Injury Severity Score (TRISS)-based studies indicated improved survival in the HEMS group as compared to the Major Trauma Outcomes Study (MTOS) cohort; some studies showed survival benefits in both the HEMS and GEMS groups as compared to MTOS. No studies were found to evaluate the secondary outcome of morbidity as assessed by QALYs and DALYs. All four studies suggested a positive benefit when HEMS was used to transfer patients to higher level trauma centres. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria.

AUTHORS' CONCLUSIONS

Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, an accurate composite estimate of the benefit of HEMS could not be determined. Although five of the nine multivariate regression studies indicated improved survival associated with HEMS, the remainder did not. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their non-randomised design. Similarly, TRISS-based studies, which all demonstrated improved survival, cannot be considered strong evidence because of their methodology, which did not randomize the use of HEMS. The question of which elements of HEMS may be beneficial for patients has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximise the potential utility of results. Large, multicentre studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

Reductions in transport mortality in Australia: evidence of a public health success

OBJECTIVE

To describe trends in transport mortality for a range of common transport types in Australia over a 30-year period (1975-1977 to 2005-2007).

METHODS

Mortality data on all-cause and transport-related causes of death were supplied by the Australian Institute of Health and Welfare (AIHW). Mortality rates, expected number of deaths and probabilities of death were compared for three time periods: 1975-1977, 1990-1992 and 2005-2007.

RESULTS

There were significant decreasing trends between 1975-1977 and 2005-2007 in all-cause and most other transport mortality types for both men and women. There were significant reductions in the contribution of transport-related mortality to all-cause mortality; however the difference in mortality between men and women (higher for men) changed little over the evaluated period.

CONCLUSIONS

Between 1975-1977 and 2005-2007 there were marked reductions in key causes of transport-related mortality amongst Australian adults, and the reductions in transport-related mortality exceeded reductions in all-cause mortality. The reductions could be attributed to better preventive measures and improved medical treatment for people involved in transport crashes. Although there is scope for further improvement, the reductions are evidence of a success in the prevention of crashes and the medical treatment of crash victims.

The variation of acute treatment costs of trauma in high-income countries

BACKGROUND

In order to assist health service planning, understanding factors that influence higher trauma treatment costs is essential. The majority of trauma costing research reports the cost of trauma from the perspective of the receiving hospital. There has been no comprehensive synthesis and little assessment of the drivers of cost variation, such as country, trauma, subgroups and methods. The aim of this review is to provide a synthesis of research reporting the trauma treatment costs and factors associated with higher treatment costs in high income countries.

METHODS

A systematic search for articles relating to the cost of acute trauma care was performed and included studies reporting injury severity scores (ISS), per patient cost/charge estimates; and costing methods. Cost and charge values were indexed to 2011 cost equivalents and converted to US dollars using purchasing power parities.

RESULTS

A total of twenty-seven studies were reviewed. Eighty-one percent of these studies were conducted in high income countries including USA, Australia, Europe and UK. Studies either reported a cost (74.1%) or charge estimate (25.9%) for the acute treatment of trauma. Across studies, the median per patient cost of acute trauma treatment was $22,448 (IQR: $11,819-$33,701). However, there was variability in costing methods used with 18% of studies providing comprehensive cost methods. Sixty-three percent of studies reported cost or charge items incorporated in their cost analysis and 52% reported items excluded in their analysis. In all publications reviewed, predictors of cost included Injury Severity Score (ISS), surgical intervention, hospital and intensive care, length of stay, polytrauma and age.

CONCLUSION

The acute treatment cost of trauma is higher than other disease groups. Research has been largely conducted in high income countries and variability exists in reporting costing methods as well as the actual costs. Patient populations studied and the cost methods employed are the primary drivers for the treatment costs. Targeted research into the costs of trauma care is required to facilitate informed health service planning.

Effective management of severe traumatic brain injury in a district hospital

The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provide a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.

Collecting core data in severely injured patients using a consensus trauma template: an international multicentre study

INTRODUCTION

No worldwide, standardised definitions exist for documenting, reporting and comparing data from severely injured trauma patients. This study evaluated the feasibility of collecting the data variables of the international consensus-derived Utstein Trauma Template.

METHODS

Trauma centres from three different continents were invited to submit Utstein Trauma Template core data during a defined period, for up to 50 consecutive trauma patients. Directly admitted patients with a New Injury Severity Score (NISS) equal to or above 16 were included. Main outcome variables were data completeness, data differences and data collection difficulty.

RESULTS

Centres from Europe (n = 20), North America (n = 3) and Australia (n = 1) submitted data on 965 patients, of whom 783 were included. Median age was 41 years (interquartile range (IQR) 24 to 60), and 73.1% were male. Median NISS was 27 (IQR 20 to 38), and blunt trauma predominated (91.1%). Of the 36 Utstein variables, 13 (36%) were collected by all participating centres. Eleven (46%) centres applied definitions of the survival outcome variable that were different from those of the template. Seventeen (71%) centres used the recommended version of the Abbreviated Injury Scale (AIS). Three variables (age, gender and AIS) were documented in all patients. Completeness > 80% was achieved for 28 variables, and 20 variables were > 90% complete.

CONCLUSIONS

The Utstein Template was feasible across international trauma centres for the majority of its data variables, with the exception of certain physiological and time variables. Major differences were found in the definition of survival and in AIS coding. The current results give a clear indication of the attainability of information and may serve as a stepping-stone towards creation of a European trauma registry.

International benchmarking of tertiary trauma centers: productivity and throughput approach

Background

Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure.

Results

The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found.

Conclusions

The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.

Comparison of mortality following hospitalisation for isolated head injury in England and Wales, and Victoria, Australia

Background

Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes.

Methods

Isolated TBI admissions (>15 years, July 2005–June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions.

Findings

Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03).

Conclusion

The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines.

Challenges of surgical trauma emergency admission

INTRODUCTION

Trauma still remains as one of the leading causes for mortality in Western civilization. The early clinical management of severely injured patients leads to structural and organizational challenges involving different specialties.

EMERGENCY DEPARTMENT

Trauma team leaders have to coordinate diagnostic and therapeutic steps in cooperation with different involved specialties. Furthermore, they have to make decisions based on contrary department-depending assessments. In addition, several special injuries commonly found in multiple traumatized patients require special attention.

RECENT DEVELOPMENT

Actually, structural changes in generating trauma networks are to be mentioned. Trauma networks suggest to improve patients survival in close cooperation between hospitals with different structural and personal capabilities. Close communication networks are required to guarantee transportation to an adequate trauma center.